CQC report explained · a nursing home
What the CQC found at Sherwood Grange
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, December 2023
Sherwood Grange was rated Good; inspectors found safe care and strong management, but some staff said more staff were needed.
This was an unannounced focused inspection. Inspectors visited early in the morning because of concerns about night staffing and people being helped out of bed before they wanted to. They also reviewed an allegation of inappropriate sexual activity between people using the service.
Inspectors found enough staff on duty during their visit. People were getting up at times that suited them. Risks, safeguarding concerns, accidents and incidents were recorded and reviewed. Medicines were managed safely, and infection control arrangements were satisfactory.
The home was well managed and had an open and person-centred culture. People, relatives, staff and healthcare professionals gave positive feedback. Audits and checks were regularly completed.
Only Safe and Well-led were inspected. Both were rated Good. Effective, Caring and Responsive were not inspected during this visit, so their previous ratings were used when calculating the overall Good rating. The previous overall rating was also Good.
Risk management
People's risks were identified and reviewed. Staff followed care plans and took action to reduce risks while allowing people to enjoy their lives.
“People had risks to them identified and understood by staff who took action to prevent and safely manage risks.” from the report
Medicines
Inspectors found medicines were stored, administered and checked safely. The records they reviewed had no errors or omissions.
“People's medicine records were kept up to date with no recording errors or omissions found on any of the MAR sheets we looked at.” from the report
Management checks
The home had regular checks covering areas such as care plans, incidents, fire safety, infection control and health and safety.
“Audits were thorough, and regularly carried out by the registered manager, staff, and the provider.” from the report
Open culture
Inspectors found the home was person-centred and inclusive. People, relatives and staff said management listened and communicated well.
“The home's culture was person-centred, open, inclusive, and empowering.” from the report
Some staffing pressure
minorInspectors found enough staff during the visit, but recruitment was continuing and some staff said more staff were needed. The report also said there was no activities co-ordinator at that time, although a replacement had been recruited.
“some staff felt that more staff were needed.” from the report
- 01How many staff are normally on duty overnight, and how do you cover sickness or absences?
- 02How will you make sure people continue to get up at the time they choose?
- 03Has the new activities co-ordinator started, and what activities are currently available?
- 04How are safeguarding concerns and incidents reviewed, and how are families told about the outcome?
- 05What were the previous ratings for Effective, Caring and Responsive, which were not inspected this time?
This was an unannounced focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 8 December 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2023
Rated Good; inspectors found safe, person-centred and well-managed care, but activities and communication with some relatives needed improvement.
Inspectors visited on 7 and 8 March 2023. The first day was unannounced. They spoke with people living in the home, relatives, staff and health professionals, and reviewed care plans, risk records, staff files and management records.
The home was rated Good overall. Inspectors found enough staff, safe medicines practice, suitable risk assessments and good infection control. People were treated kindly, given choices and supported to keep in touch with relatives and friends.
There were areas to improve. Inspectors recommended reviewing where busy activities take place. Some relatives raised concerns about inaccurate care records and mixed messages from the home. These issues were being addressed during the inspection.
The previous overall rating was Outstanding, published in October 2019. The overall rating changed to Good. Effective and Caring were not inspected during this visit, so their earlier ratings were used in calculating the overall rating.
Safety and risk management
Risks were regularly assessed and reviewed. Staff supported people to make choices and take reasonable risks safely.
“People were supported by staff to take acceptable risks and enjoy their lives safely by staff following people's risk assessments.” from the report
Medicines
Inspectors found medicines were administered, stored and checked safely. The medicine records reviewed had no recording errors or omissions.
“People's medicine records were kept up to date with no recording errors or omissions found on any of the MAR sheets we looked at.” from the report
Person-centred care
Staff knew people and their preferences well. People were offered choices and supported to follow their routines and interests.
“People received person centred care that meant they had choice; control and their needs and preferences were met.” from the report
Management checks
The home had regular audits covering areas such as care records, fire safety, infection control and health and safety.
“There were thorough, regularly reviewed audits carried out by the registered manager, staff, and the provider.” from the report
Activities and activity spaces
needs fixingThe range of activities was generally good, but some people wanted more outings. One activity took place in a room that was too small and crowded. Inspectors recommended reviewing the best areas for busy activities.
“We recommend the provider reviews where the best areas of the home are for busy activities to enhance the experience for people using the service.” from the report
Accuracy of care records
needs fixingSome relatives found errors in recorded information, including a misspelt name and incorrect gender. The errors were addressed during the inspection.
“Some relatives had expressed concerns about the information they had seen recorded about people being inaccurate.” from the report
Making formal complaints
minorThe complaints system was recorded and followed, but some relatives were unclear about how to make a formal complaint to the organisation rather than to the manager.
“some relatives were unclear about how to make official complaints to the organisation, rather than the registered manager.” from the report
- 01What activities and outings are now available, and how do you match them to each person's interests and needs?
- 02How do you make sure activities are held in spaces that are suitable and not overcrowded?
- 03How do you check care records for errors such as incorrect names, gender or other personal details?
- 04How will relatives receive consistent updates about a person's care and welfare?
- 05How can a relative make a formal complaint to the organisation, rather than only to the home manager?
This was a focused inspection that assessed Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were used for the overall rating. This explanation was written from the published report of 29 March 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Sherwood Grange
4 rated inspections over 7 years: the service has held its Good rating throughout.
- December 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2023Gooddown from OutstandingSafe: GoodWell-led: Good
- November 2019Outstandingup from GoodSafe: GoodResponsive: OutstandingWell-led: Outstanding
- April 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2016
Registered with the Care Quality Commission on 9 September 2016.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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